CARE HOME ADULTS 18-65
42-44 Lansdowne Road 42-44 Lansdowne Road Leicester Leicestershire LE2 8AQ Lead Inspector
Steve Hunnybun Unannounced 19 May 2005 at 9:30am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 42-44 Lansdowne Road Address 42-44 Lansdowne Road Leicester Leicestershire LE2 8AQ 0116 283 2780 0116 283 3243 None Lansdowne Road Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Vacant Care Home 8 Category(ies) of LD - Learning disability (8) registration, with number of places 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 6th December 2004 Brief Description of the Service: 42 - 44 Lansdowne Road is registered to provide care for eight adults with learning disabilities. The home consists of one semi-detached property and one detached property situated next door to each other. The accommodation is intended for those who are capable of semi-independent living.The home is situated close to Aylestone Road and is approximately one mile from the city centre. A regular bus service to and from the centre can be accessed close to the home. A number of shops, parks and a leisure centre are located nearby. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over five hours and was the first statutory, unannounced inspection for this year. Three residents files were tracked, one had been admitted the day before for an emergency stay and the other two had lived at the home for some time. Three residents and two members of staff spoke with the inspector. Feedback from residents was positive; they stated that the home is nice, the staff are great and that they are enabled to be independent. One resident currently finds the home a little too noisy and has asked to move to the sister home opposite. This has been agreed and he will move in a week’s time. Residents at this home are very independent and this impacts on the level of care offered and the detail present in care plans. It should be noted that the registered manager recorded on this report was still in post on the day of the inspection but was on leave during his period of notice to leave. The home’s area manager and regional director have discussed with the inspector a plan to replace the registered manager. What the service does well: What has improved since the last inspection?
There were no requirements or recommendations at the last inspection. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 Residents’ needs are assessed. EVIDENCE: All three files tracked contained assessment documents. These were generated on the homes own forms for the longer-term residents and on a community care assessment for the emergency admission. All assessments were comprehensive and up to date. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Residents’ needs are reflected in their care plans. They are enabled to make choices and decisions and risks are comprehensively assessed. EVIDENCE: All files tracked contained care plans. These were comprehensive documents and would enable new staff to meet the needs of residents. All care plans had been reviewed and the dates and outcomes of reviews recorded. Residents who spoke with the inspector stated that they are able to make decisions about their lives where appropriate. The home has recently started holding weekly residents’ meetings at which important decisions regarding the home are made. All files contained risk assessments that had been reviewed and dated. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 Residents are able to engage in meaningful activities and are given appropriate responsibilities within the home. Residents are enabled to maintain relationships with friends and families. A healthy diet is encouraged and residents are able to choose, buy and prepare their own food. EVIDENCE: Residents are supported to work or to access appropriate day care one resident who spoke with the inspector works at a local supermarket as an assistant trolley manager. He stated that staff support him in this. Another resident has a cleaning job at the home opposite. Residents are encouraged to be part of the local community. They use local pubs, shops and parks and are free to come and go as they please. All files tracked contained information about residents’ families and friends. A resident who spoke with the inspector stated that he is able to keep in touch with his family. Residents were observed preparing their own lunch on the day of the inspection. One resident told the inspector that he and his peers take turns to cook and clean the house. All four residents contribute £15 a week for food and this is used for the main grocery shop. Residents buy any personal or luxury items for themselves such as crisps or chocolate.
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The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20 Residents’ health needs are met and they are able to administer their own medication. The lack of a form to record staff checks on medication could lead to errors being missed. EVIDENCE: All files contained information regarding residents’ healthcare needs. Each file had a medical section with information regarding residents’ contacts with healthcare professionals. Residents who spoke with the inspector stated that they feel their medical needs are met. Most residents administer their own medication and this is risk assessed in their files. Residents are given choice as to how they wish to manage their medication and most choose to be given a days supply each morning. In the risk assessments it states that staff regularly check that residents are in fact taking their medication. Many residents actually sign their own medication record checks but there is nowhere for staff to record that they have checked. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents feel that their views will be listened to and that they will be kept safe. EVIDENCE: The home has a comprehensive and robust complaints procedure and residents stated that they feel able to raise concerns. The weekly residents meetings will also provide a format for residents to complain or comment on the service they receive. The home has its own policy regarding adult protection as well as the Multi-Agency Vulnerable Adult Protection document No Secrets. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,30 The premises are generally homely and comfortable, the areas outlined below need attending to. EVIDENCE: Residents have personalised their home with décor and belongings. There are a number of areas where repair or redecoration is required: Number 44, the kitchen needs redecorating and cracks to the ceiling need repairing. The downstairs bedroom and hall need decorating. Upstairs one bedroom has recently been decorated but the other two need doing. The bathroom also needs decorating. Number 42 downstairs the kitchen needs decorating, the bathroom and laundry need refurbishing and both bedrooms need redecorating. There is a hole in the wall in the hall that needs repairing. The stairs need redecorating. Both upstairs bedrooms and the bathroom need redecorating. The kitchen also needs redecorating and the radiator cover needs re-fixing to the wall. The home was clean and tidy on the day of the inspection.
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The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34,35 Residents benefit from a sound recruitment procedure and well trained staff. EVIDENCE: The home has a robust recruitment procedure; candidates are required to supply two referees and a clear CRB check. All staff follow a comprehensive training package. The inspector spoke with a member of staff who has responsibility for training who is currently completing no audit of staff training needs. All staff are registered for appropriate NVQ courses. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,42 The home needs a registered manager as soon as possible. Staff are proactive regarding health and safety. EVIDENCE: The registered manager for the home is due to leave. The company has proposed that the manager from the home opposite cover. Her application needs to be processed as soon as possible so that she can be registered. Staff complete a comprehensive training package regarding health and safety that includes fire, infection control, food hygiene and the control of substances hazardous to health. All records regarding fire safety were up to date and accurate and the home has generic risk assessments. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 1 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
42-44 Lansdowne Road Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 3 x C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23 Requirement it is required that the areas of repair and decoration detailed in this report are carried out. An action plan to be completed by the stated deadline detailing timescales and costings for the works. Timescale for action June 30th 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 20 37 Good Practice Recommendations It is recommended that a system be developed to record the outcomes of checks carried out by staff on residents administering theirown medication. It is recommended that the proposed registered manager complete the process of registration as quickly as possible. 42-44 Lansdowne Road C51 S6439 42-44 Lansdowne Road V228770 190505.doc Version 1.30 Page 19 Commission for Social Care Inspection The Pavilions 5 Smith Way Grove Park, Enderby Leicester, LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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